Articles » Quick Guide to CASP ABA Practice Guidelines for the Treatment of ASD

Quick Guide to CASP ABA Practice Guidelines for the Treatment of ASD

September 20, 2024

On May 7, 2024, the Council of Autism Services Providers (CASP) released version 3.0 of their Applied Behavior Analysis Practice Guidelines for the Treatment of Autism Spectrum Disorder.

According to CASP, “The purpose of these practice guidelines is to inform decision making regarding the use of ABA as a medically necessary, efficacious, and cost-effective treatment to develop, maintain, or restore, to the maximum practicable extent, the functioning of individuals with ASD.”

Overview
Training, Certification, Licensure, Staffing, and Service Models
Medical Necessity 
Individualizing ABA Care

Part 1: Overview

Section 1.1 – Executive Summary

This section:

  • States that the practice guidelines are to inform decision making regarding the use of ABA as a medically necessary, efficacious, and cost-effective treatment to develop, maintain, or restore, to the maximum practicable extent, the functioning of individuals with ASD
  • Clarifies that the practice guidelines are based on the best available scientific evidence and expert clinical opinion regarding the use of ABA as a behavioral health treatment for people diagnosed with ASD
  • Emphasizes that the practice guidelines provide information about standards of care in ABA that should be used in planning, implementing, and evaluating assessment and treatment services

Section 1.2 – General Principles and Considerations

This section:

  • Emphasizes that application of the guidelines and recommendations must be individualized to each patient as individualized treatment is a defining feature of ABA and a reason for its success in treating ASD
  • States that people diagnosed with ASD have the same rights to services, in accordance with generally accepted standards of care, as people with any other mental or physical health condition
  • Acknowledges that many people diagnosed with ASD have co-occurring behavioral health and medical conditions, challenging behaviors (e.g., self-injury, property destruction), and a variety of other conditions that require additional medical or behavioral health treatment

Section 1.3 – Core Concepts

This section:

  • Defines autism spectrum disorder
  • Defines applied behavior analysis
  • Identifies five core characteristics of applied behavior analysis
  • Provides essential practice elements of applied behavior analysis (i.e., the five characteristics should be apparent throughout all phases of assessment and treatment in the form of essential practice elements)

Part 2: Training, Certification, Licensure, Staffing, and Service Models

Section 2.1 – Training and Certification

This section:

  • Provides an overview of the value of certification and emphasizes the value of the ethics requirements for BACB certificants
  • Acknowledges the existence of other certification bodies but clarifies that the CASP ABA Practice Guidelines use the BACB certificant levels to exemplify how tiered models can operate in ABA service delivery
  • Reviews BCBA, BCaBA, and RBT certification levels in terms of educational, fieldwork, and maintenance requirements

Section 2.2 – Licensure of Behavior Analysts

This section:

  • Provides an overview of the purpose of licensure and how states without licensure function for behavior analysts
  • Contrasts licensure versus certification in terms of scope and enforcement
  • Acknowledges that licensure laws in some states can have additional requirements above and beyond those of the certification body

Section 2.3 – Staffing and Tiered Service-Delivery Models

This section:

  • Provides considerations on what is necessary to make tiered service delivery models effective
  • Describes the logistics with implementing two and three-tiered service delivery models
  • Provides considerations on case supervision
  • Provides a rationale for the use of tiered models and emphasizes the benefits of a carefully crafted tiered system

Part 3: Medical Necessity

Section 3.1 – Professional Associations’ Definitions

This section:

  • Provides definitions by the American Medical Association (AMA) and the American Academy of Pediatrics (AAP) on medical necessity

Section 3.2 – Definitions Under State Laws

This section:

  • Describes the two contexts in which medical necessity requirements appear in state laws
  • Clarifies that State insurance laws do not apply to employer-sponsored health plans that are “self-funded” by the sponsoring employer

Section 3.3 – Medicaid Definitions

This section:

  • Clarifies State Medicaid agencies’ responsibility for determining what services are medically necessary for eligible people
  • Explains Medicaid’s rules for children under 21 years of age and that State Medicaid agencies cannot impose any definition of medical necessity on treatment for children that would limit the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) standard

Section 3.4 – Commercial Insurance Definitions

This section:

  • Explains that Commercial insurance plans commonly specify that services are covered only if the plan’s administrators determine that the services are medically necessary
  • Clarifies that definitions of medically necessary/medical necessity can vary somewhat among different funders
  • Explains that the medical necessity definitions will typically be found in the policy documents and must be disclosed to the plan member
  • Indicates that some insurers have adopted specialized medical necessity policies tailored to specific conditions or treatments, such as ABA treatment for ASD

Section 3.5 – Funder Review of Medical Necessity

This section:

  • States that when there are questions about the appropriateness or efficacy of services in an individual, the reviewing body should include a behavior analyst with experience in ABA treatment of ASD.

Part 4: Individualizing ABA Care

Section 4.1 – Assessment

This section:

  • Describes the initial assessment process and activities, which should include:
  • Record review of patient’s history
  • Interview with relevant stakeholders
  • Direct observation/measurement techniques to gain objective information about the behavior(s) of interest (e.g., FBA, skills-based assessments, standardized assessments)
  • Risk assessment for challenging behavior and mental health concerns
  • Emphasizes that there may need to be assessment from other professionals and discusses when to consult and/or refer to other professionals (e.g., medical conditions, other situations that may be outside of scope of training/competence)

Section 4.2 – Treatment Planning: Considerations and Models

This section:

  • Provides an overview of some of the activities that should be directed and coordinated by the behavior analyst
  • Describes considerations for many areas
    • Patient age
      • Treatment based on clinical needs and not constrained by age
    • Scope of treatment and treatment intensity
      • Use of focused ABA vs. comprehensive ABA
      • Intensity that is most effective to achieve treatment goals
      • Recommendations for scope/intensity based on medical necessity independent of the patient’s schedule of activities outside of treatment or previous utilization of services
    • Case conceptualization
      • Comprehensive information accounting for various factors to guide treatment and promote coordination of care
      • Importance of case conceptualization in aiding quality assurance and oversight of ABA treatment
    • Goal and protocol development
      • Importance of short-term and long-term goals that are medically necessary, of an appropriate number, and measurable
      • Incorporation of parent/family needs and consideration of patient assent, caregiver consent, and treatment adherence and outcomes
    • Treatment settings and treatment modality
      • Patients’ clinical needs and targeted goals determine the location(s) where ABA services are delivered
      • In-person, telehealth (synchronous and asynchronous), or hybrid treatment based on numerous individualized factors
    • Safety
      • Importance of safety across environments, appropriate safety protocol implementation, and training for staff on safety procedures
    • Staffing
      • Individualized staffing decisions (including ratios) accounting for treatment setting, goals, and progress
    • Critical Environmental Variables
      • Recognition of variables when choosing treatment settings and developing a treatment plan that may impact progress or outcome
    • Generalization, Maintenance, and Prevention of Deterioration
      • Explicit planning needed for generalization and maintenance of behavioral gains achieved during treatment.
    • Preventing or Minimizing Future Disability
      • Importance of ABA treatment helping to establish capabilities relevant to current and future functioning and enhance, and prevent deterioration in, abilities that are still developing
    • Treatment Duration
      • Duration of treatment for ASD based on the patient’s individual needs and response to treatment
    • Family Members and Caregivers
      • Importance of including caregivers in various capacities and at different points during ABA treatment when possible and appropriate

Section 4.3 – Collaboration in Care: Patient Priorities, Values, and Shared Decision-Making

This section:

  • Discusses the importance of considering patient and family characteristics when developing a treatment plan and utilizing shared decision making
  • Provides suggestions on how to handle situations where the proposed treatment plan is not in alignment with certain patient/caregiver values, characteristics, or expectations

Section 4.4 – Progress and Outcome Measures

This section:

  • Acknowledges the complexity of measuring outcomes of ABA services
  • Emphasizes the importance of using valid, reliable, and appropriate proximal (short-term) and distal (long-term) outcome measures to assess progress
  • Provides several cautions to providers related to percentage of goals mastered, a prescribed battery of tests for patients, and interpreting outcomes

Section 4.5 – Treatment Implementation

This section:

  • Describes the numerous direct and indirect supervision activities, considerations with monitoring the delivery of medically necessary care, monitoring progress, and adapting treatment plans/modifying protocols
  • Discusses considerations for how much supervision to provide (e.g., ratio of supervision to direct treatment hours) and the activities of case supervision beyond supervising staff
  • Provides general guidelines regarding caseload management

Section 4.6 – Collaboration and Coordination of Care

This section:

  • Emphasizes that individuals may require coordinated care, and this care should be individualized to the needs of the patient
  • Acknowledges that behavior analysts must balance the need to provide scientifically supported treatment that maximizes patient outcomes with the need to co-treat and coordinate care with other healthcare professionals who are held to their own standards of care

Section 4.7 – Transition and Discharge Planning

This section:

  • Emphasizes that transition and discharge planning are not single events and that criteria should be established that are measurable, realistic, and individualized
  • Discusses that transition and discharge planning should be conducted in collaboration with the patient, family, and other professionals involved in the patient’s treatment
  • Establishes what should be included in a transition plan
  • Reviews the process for charge including facilitating coordination of care with future service providers, as appropriate